1
SMART on FHIR Integration to Improve
Medication Adherence
Session 95, February 13, 2019
Sarah Toy-Ding, Enterprise Clinical Informaticist, MBA
Tiffany Shields-Tettamanti, Enterprise Clinical Informaticist, RN
2
Sarah Toy-Ding, MBA
Has no real or apparent conflicts of interest to report.
Tiffany Shields-Tettamanti, RN
Has no real or apparent conflicts of interest to report.
Conflict of Interest
3
• Dignity Health – Who we are
• Issue identification and solution design
• SMART on FHIR definition
• Why is the topic important?
• Solution description
• Solution metrics
• SMART on FHIR Integration
• Implementation
• Lessons learned
• Next steps
Agenda
4
• Illustrate the challenges associated with achieving medication
adherence, especially with diverse patient populations
• Identify strategies to leverage SMART on FHIR with an aggressive
implementation timeline
• Explain how to integrate medication instructions into a portal that
provides comprehensive discharge information
• Demonstrate the importance of providing access to information
and applications at the most convenient times in the clinician’s
workflow
• Evaluate potential return on investment associated with providing
medication instruction via a dedicated discharge portal
Objectives
5
39 hospitals, and 400 care sites across 22 states
Statistically-speaking:
• 8,500+ acute care beds
• 600+ skilled nursing beds
• 9,000+ physicians
• 62,000+ employees
Ministry Alignment: CommonSpirit Health will include more than 700
care sites and 139 hospitals, with approximately 159,000 employees
across 28 states. Total combined annual revenues are estimated at
approximately $30 billion.
Dignity Health: Who we are
6
7
Dignity
Collaboration
Justice
Stewardship
Excellence
Dignity Health: Our Values
8
Issue: Dignity Health wanted a solution to improve our HCAHPS
scores, decrease our readmission rates, and broaden our options to
communicate in languages other than English or Spanish.
Solution: Partnered as an early adopter with Cerner and a small
start-up company. The partnership provided an energetic, exciting,
and fun opportunity to integrate with SMART on FHIR to produce a
rapid rollout.
Issue Identification and Solution Design
9
• Description of SMART on FHIR
– SMART= Substitutable Medical, Applications Reusable
Technologies*
– FHIR= Fast Healthcare Interoperability Resources*
– Makes an “app” store for healthcare possible
– Open standards-based technology platform that enables
innovators to create apps which seamlessly and securely run
across the health care system
What is SMART on FHIR?
*http://smarthealthit.org/wp-content/uploads/SMART-on-FHIR-White-Paper-for-HIMSS-15-06Apr2015.pdf
10
• Dignity Health facts for SMART on FHIR
– Meducation® was one of the first SMART on FHIR
applications used with our Cerner platform
– Meducation® has the largest scope of any other applications
currently in use
What is SMART on FHIR? (con’t)
12
Medication adherence and its impact:
• 30-50% of medications are not taken at all, or not as instructed
• Medication adherence is associated with
– 10% of hospitalizations**
– 26% of ALL avoidable readmissions**
– Poor medication compliance is related to 125,000
deaths/year ***
– Cost of non-adherence is $290 billion/year ****
– 72% of post-discharge adverse events
Why does it matter?
** Quick Guide to Health Literacy. https://health.gov/communication/literacy/quickguide/Quickguide.pdf
*** Viswanathan M, Golin CE, Jones CD, Ashok M, Blalock SJ, Wines RC, Coker-Schwimmer EJ, Rosen DL, Sista P, Lohr KN. Interventions to improve adherence to
self-administered medications for chronic diseases in the United States: a systematic review. Ann Intern Med. 2012 Dec 4;157(11):785–95.
**** NEHI Research Brief-August 2009. Thinking Outside The Pillbox: A System-wide Approach to Improving Patient Adherence for Chronic Disease.” NEHI, 2009
13
• Health literacy is the capacity to
obtain, communicate, process, and
understand basic health
information*
• 44 million adult Americans read
below an 8
th
grade reading level**
• IOM estimates one in three
Americans are challenged by
complex information such as
• reading prescription labels
• taking their medications
correctly
Low Health Literacy is COMMON
*Nielsen-BohlmanLT, PanzerAM, HamlinB, KindigDA, eds. Institute of Medicine. Health literacy: a prescription to end confusion. Committee
on Health Literacy, Board on Neuroscience and Behavioral Health. Washington, DC: National Academies Press. April 2004.
**National Institute for Literacy, National Center for Adult Literacy, The Literacy Company, U.S. Census Bureau
14
Typical Patient Education
Detailed patient education – often
formatted in small font to fit on one page,
provided in one language
*Nielsen-BohlmanLT, PanzerAM, HamlinB, KindigDA, eds. Institute of Medicine. Health literacy: a prescription to end
confusion. Committee on Health Literacy, Board on Neuroscience and Behavioral Health. Washington, DC: National
Academies Press. April 2004.
15
Personalized Instructions
Reduce
medication
errors with
patient-
specific
Instructions
Improve medication
adherence with Regimen
Summary
Demonstrate
proper medication
administration
techniques
through videos
16
• Patient population
language diversity
• 21% of patients are
limited English proficient*
• 43% speak a language
other than English (in the
state of CA)*
• Prior to implementation,
we were only able to
provide medication
education in English and
Spanish upon discharge
Language Diversity for Printed Patient Education
*Referenced from: https://www.census.gov/data-tools/demo/languages/language_map.html?#
17
Printed examples: Font and Language Choices
18
Discharge instructions are integrated into our EHR discharge
instructions and patient portal
Discharge Instructions & Patient Portal
• Write back into patient record
• Drive traffic to help meet
Meaningful Use requirements
for 10% patient electronic
access
19
Improved Understanding & Adherence
25%
55%
53%
65%
45%
37%
79%
63%
73%
22%
Could ID side
effects
When in the
day
How long to
take
How many
times
Missed a dose
Standard Meducation
52% Improved Understanding & Adherence
Retrieved from: http://www.hbs.edu/openforum/openforum.hbs.org/goto/challenge/hbs-hms-health-acceleration-challenge/meducation-
delivering-medication-instructions-that-every-patient-can-understand.1.html
20
Improved Medication Adherence at the VA
65%
43%
39%
21.7%
36%
18%
22.7%
4.5%
0%
10%
20%
30%
40%
50%
60%
70%
…Sometimes forget
to take my heart
medicines"
…Am sometimes
careless with how I
take my heart
medicines"
…Have trouble
remembering what
my medicines are
for"
…Forgot to take my
heart medicine
yesterday"
Patients “Agree or Strongly Agree” that I ...
Baseline 90 days later
77%
Improvement
Retrieved from: http://www.hbs.edu/openforum/openforum.hbs.org/goto/challenge/hbs-hms-health-acceleration-challenge/meducation-
delivering-medication-instructions-that-every-patient-can-understand.1.html
21
Patient Satisfaction Low Health Literacy
52%
98%
85%
4%
1%
1%
0% 20% 40% 60% 80% 100%
Staff describe medicine side
effect
Tell you what new medicine was
for
Communication About
Medicines
Percentile Rank
Baseline 90 Days Later
HCAHPS Overall Percentile
Increased HCAHPS scores & increased VBP payment in 90 days
Retrieved from: http://www.hbs.edu/openforum/openforum.hbs.org/goto/challenge/hbs-hms-health-acceleration-challenge/meducation-
delivering-medication-instructions-that-every-patient-can-understand.1.html
22
Via SMART on FHIR
How the Integration Works
• Integration is via standard FHIR web service
• SMART on FHIR provides a method for apps to launch securely
within the EMR
• Users access Meducation as an MPage component from within
workflow
Meducation Integration with Dignity EHR
Dignity Health Cerner FDB
• Licensed the “Ignite”
web service from
Cerner
• Tested the web service
integration
• Configured the FHIR
web service
• Configured Meducation
documents to be made
part of the depart
summary
• Provided testing
support and
issue resolution
23
• 35 accelerated implementations across
our 35 acute hospitals in 5 months
• Pilot selection included one department
from each of our 35 acute care
hospitals; we delivered the new solution
to 35 units successfully in the 1st week
of implementation
• 262,130 medication regimen calendars
have been distributed, including
education for more than 1.4 million
discharge medications.
Implementation by Numbers
24
• Clearly define training methodology
• Know current state medication reconciliation processes
• Home medication documentation can be incomplete
• Understanding the current time spent on patient education
during discharge
• Engage leadership early
• Take risks
• Define domain strategy
• Understand vendors FHIR
maturity
Lessons Learned
25
Feedback
Nursing
Much more engaged in counseling patients on their meds
Appreciate being able to communicate with patients in their
language and provide multiple font sizes
Creates length to printed discharge instructions
Patients & Caregivers
Better understanding and fewer
questions on their instructions
Calendar view ease of use for all
26
• Discharge & Med Rec process optimization
• Automatic feed of patient language preference field from EHR to
Discharge Medication Education App (one less click)
• Expansion to use Meducation Bedside to improve HCAHPS
scores on inpatient medication communication
• Expansion to ambulatory clinics for use of Meducation through
transitions of care
Optimization & Next Steps
27
Current State
Clinicians are asked to complete
discharge medication education
outside of the discharge summary
workflow
Current State: Discharge Medication Education
28
Future State
Clinicians will be able to complete discharge medication
education within the discharge Mpage
Future State: App Embedded in Discharge
Summary Workflow
29
Dignity Health mission, vision, and values
If patients do not understand what we are
teaching them, they cannot make the right
decisions about their health and they cannot
follow their treatment plan
Patients feel able to manage their health
needs; they are empowered and capable
Patient-centered care - the responsibility is
on us to teach effectively, not the patient’s
ability to learn
It improves communication between
patients and clinicians
Why Education Matters
